Research & Sources

Just 5% of in-network ACA Marketplace denials cite "lack of medical necessity" — most cite administrative, coverage, referral, or other reasons

KFF

Claims Denials and Appeals in ACA Marketplace Plans, 2024 — full breakdown: 36% "Other" (unspecified), 25% Administrative, 16% Excluded service, 9% Lack of prior authorization or referral, 5% Medical necessity, plus smaller categories.

19% of in-network ACA Marketplace claims were denied in 2024 — similar to 2023 and to previous years

KFF

Claims Denials and Appeals in ACA Marketplace Plans, 2024 — out-of-network denial rate: 37%. Denial rates ranged from 3% to 36% across insurers in HealthCare.gov states.

Approximately 85 million in-network claims were denied on HealthCare.gov in 2024 — out of about 451 million in-network claims, which were 91% of the 496 million total claims insurers reported

KFF

Claims Denials and Appeals in ACA Marketplace Plans, 2024: insurers reported receiving about 496 million claims in 2024; 451 million of them (91%) were for in-network services, and roughly 85 million of those were denied, a 19% in-network denial rate. The 451 million and 496 million figures on this page are the same filing counted two ways — in-network claims only, and all claims.

HealthCare.gov issuers separately reported 262,982 internal appeals — appeal volume equal to about 0.31% of reported in-network denials

KFF

The appeal and denial fields are aggregate reporting, not linked case records, so 0.31% is best described as an appeal-volume ratio rather than proof that a specific share of individual denials went unappealed. CMS also suppresses small values, making 262,982 a minimum. The field covers formal internal appeals, not informal phone calls or other pushback.

Insurers overturned 34% of internally appealed HealthCare.gov denials in 2024 — roughly a third of marketplace internal appeals succeeded

KFF

Claims Denials and Appeals in ACA Marketplace Plans, 2024 (published March 2026) — KFF analysis of CMS Transparency in Coverage filings covering roughly 496 million claims in total (451 million of them in-network) from 157 reporting insurers. At 34%, roughly one in three internal appeals succeeds — while formal appeal volume runs well under 1% of denials.

About half of insured adults who were denied care challenged the denial informally (usually by phone) — but only 15% of consumers with denied claims filed a formal appeal

The Commonwealth Fund / KFF

Commonwealth Fund 2025 Health Care Affordability Survey (released June 2026) — roughly half of denied patients pushed back in some form. Among those who challenged: 30% got the recommended care approved, 25% got an alternative covered, and 33% got a bill reduced or eliminated. KFF's 2023 Survey of Consumer Experiences with Health Insurance found only 15% filed a formal appeal. This is why Lysco scopes every appeal-gap figure to formal appeals and states it as a volume ratio — the unscoped version would be wrong.

21% of privately insured working-age adults had care denied by their insurer in the past year

The Commonwealth Fund

"How Health Insurance Coverage Denials Affect Americans," findings from the 2025 Health Care Affordability Survey (published June 2026). SSRS interviewed 6,353 adults ages 19–64 from July 22 to October 27, 2025; the denial analysis covers the 4,589 with private insurance. The 21% combines 13% who reported a prior-authorization denial, 8% a claim denial, and 1% both. More than half of the denied bills were $1,000 or more, and nearly 70% of those with a claim denial said it cost their household more money.

43% of insured adults whose claim was denied say the denial created medical debt they are still paying off

The Commonwealth Fund

2025 Health Care Affordability Survey, published June 2026 (fielded July–October 2025).

4 in 5 appealed Medicare Advantage prior-authorization denials (80.7%) were fully or partially overturned in 2024

KFF

Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations, 2024 (published January 2026) — KFF analysis of CMS contract-level reporting data covering essentially all MA contracts. Caveats: "partially overturned" counts as an overturn, the rate is measured at plan-level (first-level) appeal, and people who appeal are a self-selected group with stronger cases. By insurer, 2024 overturn rates ran from 51.0% (Kaiser Foundation Health Plan) to 95.5% (Centene).

Historical: Medicare Advantage plans overturned 75% of their own denials on appeal in 2014–2016 — roughly 216,000 denials a year

HHS Office of Inspector General (OIG), report OEI-09-16-00410

"Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials," issued September 25, 2018, covering 2014–2016 appeal data. Listed for historical continuity only — the current figure Lysco cites is the 80.7% KFF 2024 number above. Correction note: an earlier version of this page attributed the 75% to OIG report OEI-09-18-00260 (the 2022 prior-authorization study), which does not contain it.

82% of Medicare Advantage skilled-nursing admission denials went unappealed; among the 2,445 appeals filed, 95% (2,313) were overturned

HHS Office of Inspector General (OIG), June 2026

Report OEI-09-24-00331 analyzed June 2024 data from 19 large Medicare Advantage organizations covering 29.3 million enrollees, or 86% of Medicare Advantage enrollment at the time. The organizations denied about 13,500 of 109,400 skilled-nursing-facility admission requests; enrollees or providers appealed 2,445 denials, and plans overturned 2,313 in favor of the enrollee. Scope caveat: this was one month of one service category, and OIG said the aggregate analysis could not determine how many initial denials were inappropriate.

Only 11.5% of Medicare Advantage prior-authorization denials are appealed

KFF

Medicare Advantage prior-authorization data, 2024 reporting cycle (published January 2026). 4.1 million MA prior-auth denials in 2024 (7.7% denial rate, up from 5.7% in 2019).

HHS OIG estimated that 13.3% of denied Medicare Advantage prior-authorization requests met Medicare coverage rules

HHS Office of Inspector General (OIG), April 2022

Report OEI-09-18-00260 reviewed a stratified sample of 247 eligible prior-authorization denials representing 12,273 denials issued by 15 large Medicare Advantage organizations during June 1–7, 2019. OIG projected that 1,631 of those denials met Medicare coverage rules (13.3%; 95% confidence interval: 8.9%–19.3%) and likely would have been approved under original Medicare. The organizations represented nearly 80% of Medicare Advantage enrollment; this one-week 2019 sample should not be presented as a current rate for every plan or service.

Published external-review outcomes vary widely by state and case type

CA DMHC, MD Insurance Admin, CT OHA, PA Insurance Dept, NY DFS

The cited programs range from 42% fully plus 2% partially overturned in New York (2023) to about 80% reported by Connecticut's Office of the Healthcare Advocate. California IMR reports ~73%, Maryland 64%, and Pennsylvania ~50%. These figures are not a prediction for an individual case.

Only 40% of US consumers know they have a legal right to appeal externally

KFF

Survey of Consumer Experiences with Health Insurance, 2023 — 51% are unsure; 9% don't believe they have appeal rights. Marketplace enrollees are least aware (34%).

66% of insured adults call insurance delays and denials a "major problem" — and 33% had a service or medication denied in the past two years

KFF

KFF Health Tracking Poll fielded January 13–20, 2026 and published February 2, 2026 ("Prior Authorizations Rank as Public's Biggest Burden When Getting Health Care"). Spans employer, Marketplace, Medicare, and Medicaid coverage.

A growing list of states — including California, Texas, Arizona, Nebraska, and Maryland — has enacted laws limiting how insurers may use AI or automated systems to deny care

State statutes, 2024–2026, as tracked by KFF

California SB 1120 (the "Physicians Make Decisions Act," effective January 1, 2025) requires that a licensed physician, not an algorithm, decides medical necessity. Texas SB 815 (effective September 1, 2025) bars a utilization-review agent from using an automated decision system to make an adverse determination in whole or in part. Arizona HB 2175 and Nebraska LB 77 (2025) bar AI output from being the sole basis for denying, delaying, or modifying care. Maryland HB 820 (2025) requires AI used in utilization review to account for the patient's medical history and individual circumstances and to be open to state inspection. KFF's May 2026 brief, "Regulation of AI in Prior Authorization and Claims Review," also lists Illinois, Washington, Utah, Indiana, and Alabama. Many of these laws followed reporting that one major insurer's review system denied 300,000+ claims at an average of 1.2 seconds of physician review each (see the ProPublica entry below).

95% of surveyed physicians report that prior authorization delays access to necessary care, and 26% report it led to a serious adverse event for a patient in their care

American Medical Association (AMA)

2025 AMA Prior Authorization Physician Survey — a 44-question web survey administered December 2025 to 1,000 practising US physicians (400 primary care / 600 specialists) drawn from the Medscape panel, published 2026. Also: 94% report PA increases physician burnout; 79% report PA can at least sometimes lead to treatment abandonment; 35% report PA criteria are rarely or never evidence-based; 40% report PAs are often or always denied. Scope caveat: these are physician survey responses about their own practice experience, not measured patient incidence rates.

Physicians and their staff spend about 13 hours a week completing prior authorizations

American Medical Association (AMA)

2025 AMA Prior Authorization Physician Survey (same instrument as the entry above). 40% of physicians have staff who work exclusively on prior authorizations.

US hospitals spend an estimated $19.7 billion per year managing denied claims

Premier Inc.

Premier Trend Alert, "Private Payers Retain Profits by Refusing or Delaying Legitimate Medical Claims," published March 21, 2024. National survey of hospitals, health systems, and post-acute providers: nearly 15% of claims to private payers are initially denied; providers spend an average of $43.84 per claim fighting them; 54.3% of denied private-payer claims are ultimately overturned and paid.

Cigna doctors denied over 300,000 requests for payment using an algorithmic review process, averaging 1.2 seconds per case

ProPublica and The Capitol Forum (March 25, 2023 — Patrick Rucker, Maya Miller, and David Armstrong)

Investigation into Cigna's PXDX system: "Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show." Findings were repeated verbatim in California and Connecticut federal class-action complaints filed in 2023. Correction: an earlier version of this page attributed the story to a different reporter.

UnitedHealthcare's skilled-nursing-facility denial rate increased ninefold (9x) from 2019 to 2022, coinciding with the deployment of an internal AI tool (nH Predict)

US Senate Permanent Subcommittee on Investigations

Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care, October 2024. Report focused on UnitedHealth's NaviHealth subsidiary.

Medicare Advantage processed 53 million prior-authorization determinations in 2024

KFF

Nearly 53 million (52.8 million) determinations, up from 49.8 million in 2023. 4.1 million denials at a 7.7% denial rate. Prior-auth denial rate by parent company: UnitedHealth Group 12.8%; Centene 12.3%; CVS Health (Aetna) 11.9%; Kaiser Foundation Health Plan 10.9%; Humana 5.8%; Elevance Health 4.2%. Insurers with fewer than 1 million MA enrollees are grouped as "other insurers" (5.5%).

CMS 2026 rule: 72-hour urgent / 7-calendar-day standard prior-authorization decisions required for Medicare Advantage, Medicaid, and CHIP plans

Centers for Medicare & Medicaid Services (CMS)

CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). "Impacted payers" are Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans, and qualified health plan issuers on the federally facilitated exchanges (FFEs). The decision timeframes apply to MA, Medicaid, and CHIP plans; FFE Marketplace QHPs are excluded from the timeframes (their urgent decisions follow ACA claims rules, 45 CFR 147.136) but must give specific denial reasons and post metrics. Plans sold on fully state-run exchanges may fall outside the rule. Commercial and ERISA self-funded plans are not impacted payers. Drug prior authorization is outside the rule; the drug PA rule (CMS-0062-P) is proposed, with compliance proposed for Oct 2027.

Americans owe an estimated $220 billion in medical debt

KFF analysis of the Survey of Income and Program Participation (SIPP)

"The Burden of Medical Debt in the United States," published February 12, 2024, using data from the 2021 SIPP. Debt distribution is highly skewed: ~14 million Americans (6% of adults) owe more than $1,000; ~3 million (1%) owe more than $10,000. This is a "$220 billion at least" floor, not a ceiling.

100 million Americans carry medical or dental debt

KFF/NPR

Health Care Debt Survey, 2022 — broader definition (includes past-due bills, balances being paid off over time, medical credit cards, and personal loans for healthcare). Roughly 41% of US adults.

36% of US households carried medical debt in 2024 — roughly $194 billion estimated in active collections

Health Affairs Scholar (Fulford and Wilson, August 2025)

"Medical debt and collections in the United States," published August 11, 2025, using two nationally representative 2024 surveys: 21% of households had a past-due medical bill, 23% were paying one off over time, and 17% had borrowed to pay one. Complements KFF's broader $220B total-owed estimate and CFPB's narrower credit-report figure — each measures a different slice of the same problem. Correction: an earlier version of this page attributed the study to JAMA Health Forum.

About two-thirds of US consumer bankruptcies (~66.5%) cite medical bills as a contributor

Himmelstein et al., American Journal of Public Health

Medical Bankruptcy: Still Common Despite the Affordable Care Act, 2019 — 65.5% pre-ACA / 67.5% post-ACA. Broad-definition study (any household with >$1,000 in medical bills, mortgaging a home for medical bills, or losing 2+ weeks of work to illness). More conservative definitions place medical-cause bankruptcies in the 20–60% range.

31 million Americans borrowed an estimated $74 billion in 2024 to pay for healthcare

West Health-Gallup Healthcare Survey

Fielded November 11–18, 2024 (n=3,583); published March 5, 2025. 11% of US adults are classified as "Cost Desperate" — unable to afford or access quality care.

About 37% of US adults would not have covered an unexpected $400 expense entirely with cash or its equivalent in 2025 — 63% said they would

Federal Reserve — Survey of Household Economics and Decisionmaking (SHED), 2025 data (released May 2026)

"Economic Well-Being of U.S. Households in 2025": 63% of adults said they would cover a hypothetical $400 emergency expense exclusively using cash, savings, or a credit card paid off at the next statement, so the remaining 37% would have paid some other way or could not have paid. The same report found that 26% of adults skipped medical treatment in 2025 because of cost, down from 28% in 2024. Correction: an earlier version of this page inverted the $400 figure and cited the 2024 report.

Approximately 50% of US adults could not pay an unexpected $500 medical bill without borrowing

KFF

Health Care Debt Survey and follow-up reporting. Of those, 19% could not pay it at all; 5% would have to borrow from a bank, payday lender, or family; 21% would put it on a credit card and carry the balance.

As of June 2023, an estimated 15.6 million consumers had at least $49.2 billion in medical collections on their credit records

Consumer Financial Protection Bureau (CFPB), March 2024

CFPB found 325,788 consumers with a medical collection in its roughly 1-in-48 Consumer Credit Panel and scaled that count to an estimated 15.6 million consumers. It similarly estimated $49.2 billion in medical-collection balances at the nationwide credit-reporting agency supplying the panel. CFPB describes $49.2 billion as a lower bound: collections are not always reported to every bureau, many are never credit-reported, and total medical debt is larger than medical debt in collections.

Roughly 1 in 5 US hospitals have denied non-emergency care to patients with unpaid bills

KFF Health News — "Diagnosis: Debt"

Investigative series, 2022–2024. Many additional hospitals retain formal policies allowing the practice even when not actively enforced. Some hospitals also push patients toward medical credit cards charging up to 29% interest.

GoFundMe has said it hosts more than 250,000 medical fundraising campaigns a year

GoFundMe company statement, reported by CBS News (February 2020)

CBS MoneyWatch, "As medical costs soar, more Americans turn to crowdfunding" (February 21, 2020): GoFundMe said the site hosts more than 250,000 medical campaigns per year, raising more than $650 million collectively. This is a company-reported figure, not an independent count, and it has not been updated here since. Its then-CEO had earlier told CBS that about one-third of all donations on the platform go toward health care costs. For scale from an independent source: a peer-reviewed study of 437,596 US medical campaigns from 2016–2020 (Kenworthy and Igra, American Journal of Public Health, 2022) found that roughly nine in ten did not reach their fundraising goal.

61.8% of people who negotiated a problematic medical bill reported a lower price

JAMA Health Forum

Disparate Patient Advocacy When Facing Unaffordable and Problematic Medical Bills, 2024.

Nonprofit hospitals are required to maintain financial assistance policies (501(r))

Internal Revenue Service (IRS)

Section 501(r) Requirements for Charitable Hospitals — requires policies to be widely publicized and limits how much can be charged to patients eligible for assistance.

About 1 in 5 US adults recently got a medical bill they disagreed with or could not afford — and of those who contacted the biller about a perceived error, 74% got the mistake corrected

JAMA Health Forum / USC Schaeffer Center

Peer-reviewed study published August 2024, using the probability-based, nationally representative Understanding America Study panel (n=1,135; fielded August–October 2023). 62% of those who negotiated a price got it lowered. Caveats: outcomes are self-reported, and the success rates are measured among the roughly 6 in 10 billed adults who chose to reach out — not among everyone with a problem bill.

Medicare paid an estimated $28.8 billion improperly in fiscal year 2025 — 6.55% of Medicare Fee-for-Service dollars

CMS Comprehensive Error Rate Testing (CERT) program

FY2025 Improper Payments Fact Sheet (FY2024: 7.66%, $31.7 billion). A federal audit that re-reviews statistically sampled claims against medical records. Caveats: "improper" includes insufficient documentation and underpayments, not only overcharges, and the rate is dollar-weighted for Medicare Fee-for-Service only — it cannot be read as "X% of bills contain errors."

Retired claims: "49–80% of medical bills contain errors" and "$1,300 average error on hospital bills over $10,000"

Historical — NerdWallet Health (2014) / Medical Billing Advocates of America

These widely repeated figures trace to a 2014 NerdWallet analysis of OIG Medicare hospital-compliance audits and to unpublished reviews by a billing-advocacy group; a 1990s Equifax audit of large hospital bills sits behind many "$1,300" citations. No study published since 2020 supports a per-bill error rate or average error dollar figure of that shape, so Lysco retired both claims in July 2026 and no longer cites them. They are listed here for transparency because older articles still repeat them. The strongest modern evidence that challenging bills works is the 2024 JAMA Health Forum study above.

Average emergency-department visit cost for people with large-employer coverage: $2,453 paid by enrollee and insurer combined, with $646 out-of-pocket

Peterson-KFF Health System Tracker (2019 claims data, published December 2022)

"Emergency department visits exceed affordability threshold for many consumers with private insurance," published December 16, 2022, using 2019 claims from the Merative MarketScan Commercial Database (large-employer plans). Appendicitis visits were the most expensive diagnosis examined, at about $9,535 per visit ($1,717 out-of-pocket). Caveat: these are 2019 prices for privately insured patients, not current list prices or uninsured charges. Correction: an earlier version of this page labelled the analysis "2024" and added an unsourced uninsured-patient figure.

HIPAA access rights may include billing records held by covered entities

US Department of Health and Human Services (HHS)

45 CFR §164.524 generally lets an individual inspect or obtain a copy of protected health information in a designated record set held by a HIPAA-covered entity, including billing records. It does not guarantee a custom itemized bill from every provider. State law may add itemized-statement rights, and HIPAA timing and extension rules apply to covered access requests.

Contingency medical-bill negotiators and billing advocates keep roughly 10–35% of whatever they save you

Consumer Reports

Consumer Reports, "How to Get Help With Your Medical Bills": billing advocates "typically charge $100 or more an hour," and those working on contingency take "a percentage of what they save you, usually 25 percent to 35 percent." The 10% floor in Lysco's pricing comparison reflects the lowest tiered contingency rate we found in published 2026 service pricing; Lysco does not name, evaluate, or endorse individual services.

No Surprises Act IDR volume more than doubled year over year — 1.2 million new disputes in the first half of 2025 against nearly 590,000 in the first half of 2024

Georgetown Center on Health Insurance Reforms (CHIR), analysis of CMS IDR public use files

Cumulative volume reached 3.4 million disputes from 2022 through June 2025, and nearly 1.4 million more were filed July–December 2025, for 4.8 million total through the end of 2025. Federal officials had expected roughly 17,000 disputes a year. Providers won 88% of determinations in the first half of 2025, up from 85% in 2024 and 81% in 2023. CHIR estimated total IDR-related costs at about $5 billion through the end of 2024, and expects that figure to have risen substantially through 2025.

When one provider's or facility's bill is at least $400 more than its own Good Faith Estimate, the federal dispute process (Patient-Provider Dispute Resolution) may be available if its other requirements are met

Centers for Medicare & Medicaid Services (CMS)

No Surprises Act — Patient-Provider Dispute Resolution process. Available to self-pay and uninsured patients.

45% of insured working-age adults received a medical bill or copay charge in the past year for care they believed should have been free or covered

The Commonwealth Fund

Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S., August 2024 — nationally representative survey (n=7,873 adults; 5,602 insured working-age adults analyzed; fielded April–July 2023). 17% said their insurer denied coverage for doctor-recommended care. Caveat: this is self-reported perception — some of these bills reflect a misunderstanding of benefits rather than a verified billing or coverage error.

36% of US adults skipped or postponed care due to cost in the past 12 months

KFF Health Tracking Poll, May 2025

KFF, "Americans' Challenges with Health Care Costs" (page updated April 30, 2026), which attributes this figure to the KFF Health Tracking Poll fielded May 5–26, 2025. Three-quarters of uninsured adults said they skipped or postponed needed care, and 18% of all adults said their health got worse because of skipped or delayed care. Correction: an earlier version of this page labelled the poll "2024."

43% of US adults did not take medication as prescribed because of cost

KFF Health Tracking Poll, February–March 2026

Same KFF page, attributing the figure to the KFF Health Tracking Poll fielded February 24 – March 2, 2026. Includes 27% who did not fill a prescription, 19% who cut pills in half or skipped doses, and 31% who took an over-the-counter drug instead. About half of adults in households earning under $40,000 (52%) reported not taking a medication as prescribed because of cost.

Roughly 30% of people with a chronic illness skip doses, cut pills in half, or leave prescriptions unfilled due to cost

KFF

Includes about 25% of adults who had health insurance for the full year.

National health spending reached $5.3 trillion in 2024 (18.0% of GDP) — about $15,474 per person

Centers for Medicare & Medicaid Services (CMS)

National Health Expenditure Accounts, 2024. Hospital spending: $1.63T (+8.9%); physician services: $1.11T (+8.1%); prescription drugs: $467B (+7.9%).

US health spending per person is nearly 2x the average of comparable wealthy countries

Peterson-KFF Health System Tracker (OECD data)

"How does health spending in the U.S. compare to other countries?": health consumption expenditures per person averaged $14,775 in the US in 2024, against $7,860 across comparable high-income countries, and almost $5,000 more than the next-highest, Switzerland (about $9,775). Note the two per-person figures on this page measure different things: the CMS National Health Expenditure total above ($15,474) includes investment, public-health, and administration spending, while the tracker uses the OECD-comparable "health consumption" measure.

Health spending is projected to reach 20.3% of GDP by 2033

CMS Office of the Actuary

National Health Expenditure Projections 2024–2033. Average annual growth of 5.6%, outpacing GDP growth of 4.3%. Medicare spending projected to grow 7.4%/year through 2032.

Average employer-sponsored family premium: $26,993 in 2025 (+6% YoY, +24% over five years)

KFF

2025 Employer Health Benefits Survey. Single coverage: $9,325. Workers contribute $6,850 toward family coverage on average. 34% of covered workers face a deductible ≥$2,000 (53% at small firms with 10–199 workers).

44% of adults say healthcare costs are very or somewhat difficult to afford

KFF Health Tracking Poll, May 2025

KFF, "Americans' Challenges with Health Care Costs" (page updated April 30, 2026), attributing the figure to the KFF Health Tracking Poll fielded May 5–26, 2025.

23% of working-age adults with year-round coverage are underinsured

The Commonwealth Fund

Biennial Health Insurance Survey, 2024. 66% of the underinsured have employer coverage. 57% reported avoiding care due to cost; 44% had medical debt.

27.1 million Americans were uninsured in 2024 (8% of the population)

US Census Bureau

Current Population Survey and American Community Survey, 2024. Working-age (19–64) uninsured rate: 11.3%. The ACS-measured uninsured rate ticked up from 7.9% in 2023 — the first increase in years, driven mostly by Medicaid unwinding.

24.2 million people selected ACA Marketplace plans for 2025; 23.0 million did for 2026, the first open enrollment after the enhanced premium tax credits expired

CMS Marketplace Open Enrollment Period national snapshots (2025 and 2026)

The 2025 snapshot counted 24,166,491 plan selections — roughly double the 12 million of 2021, a rise driven by the enhanced premium tax credits in effect from 2021 through 2025. The 2026 snapshot (January 2026) counted 22,973,219 plan selections: 15.8 million on HealthCare.gov and 7.2 million on state-based exchanges, about 1.2 million fewer than the year before. Plan selections are not the same as effectuated enrollment, which is lower once unpaid premiums are counted.

Roughly 27 million people disenrolled from Medicaid after the post-pandemic unwinding

KFF / GAO

KFF Medicaid Enrollment and Unwinding Tracker. 69% of disenrollments were procedural (not eligibility-based).

Before the enhanced ACA premium tax credits lapsed, KFF projected that subsidized enrollees' premium payments would rise 114% on average — from $888 to $1,904 a year

KFF / CBO (pre-expiration projections)

KFF analysis published September 2025, before the enhanced credits expired at the end of 2025. CBO projected roughly 10 million more people uninsured by 2034 under the 2025 "One Big Beautiful Bill Act" plus subsidy expiration. Listed as the pre-expiration projection; the entry below reports what happened once the credits lapsed.

The subsidy cliff arrived: benchmark ACA premiums rose ~26% for 2026, and ~9% of 2025 enrollees were already uninsured by early 2026

KFF

Enhanced premium tax credits expired at the end of 2025. Average paid premiums rose ~58% as many enrollees bought down to higher-deductible plans; 55% of re-enrollees report cutting basic household spending to keep coverage.

Hispanic Americans face the highest uninsured rate at 24.6% among adults 18–64

KFF / National Health Interview Survey (NHIS)

2024 NHIS data — nearly four times the rate of non-Hispanic Whites (7.9%).

92.3 million people live in primary-care shortage areas

Health Resources and Services Administration (HRSA)

Health Professional Shortage Area Statistics, January 2026.

137.1 million people live in mental-health shortage areas

HRSA

Mental Health HPSA Designations.

Projected 141,160 FTE physician shortfall by 2038

HRSA

Physician Workforce Projections, 2025.

76.4% of adults had at least one of 12 selected chronic conditions in 2023, and 51.4% had more than one

Centers for Disease Control and Prevention (CDC), Preventing Chronic Disease, 2025

"Trends in Multiple Chronic Conditions Among US Adults, by Life Stage, Behavioral Risk Factor Surveillance System, 2013–2023" (Preventing Chronic Disease, 2025): in 2023, 76.4% of US adults (more than 194 million people) reported at least one of 12 selected chronic conditions and 51.4% (131 million) reported multiple. Correction: an earlier version of this page attributed the figure to the National Health Interview Survey; the data source is BRFSS.

Over-65 population projected to reach 21% of total by 2040

Economic Report of the President, 2024

Chapter on Population and Aging.

Medicaid Long-Term Services and Supports spending reached $228.6 billion in 2023, with home- and community-based services accounting for $145.9 billion

CMS (brief prepared by Mathematica)

"Medicaid Long-Term Services and Supports Users and Expenditures by Service Category, 2023," published on Medicaid.gov. The companion 2022 brief counted 9.1 million Medicaid LTSS users; the 2023 user count is not restated here because Lysco could not re-read it in the September 2026 pass.